1. Introduction This slide set is intended for use by qualified clinical staff e.g. Nurse Advisors and Dental Nurse Advisors It provides basic information on: The use of analgesics in managing pain The dangers of deliberate or accidental overdose with common, simple analgesics Guidance on restarting analgesics after accidental overdose Further information can be found in the BNF and NHS Evidence 1Dental Pain Guidance UKMi October 2015

2. Learning outcomes 1.Outline the key features of paracetamol, ibuprofen and other simple analgesics 2.Understand how and why overdoses of analgesics occur 3.Know when to refer calls about paracetamol and ibuprofen 4.Be able to give appropriate restarting guidance 2Dental Pain Guidance UKMi October 2015

3. Why worry about overdoses? Very common Harm to the patient Self harm / psychological issues Medicines readily available Patient misconceptions of safety Risk factors Dental pain 3Dental Pain Guidance UKMi October 2015

4. Supratherapeutic overdoses Examples: Taking ibuprofen every 3 hours instead of every 6-8 hours as pain isn’t controlled Taking paracetamol along with co-codamol tablets for extra pain relief, without realising both contain paracetamol Taking 3 paracetamol tablets per dose instead of 2 tablets Taking more than the recommended maximum dose for therapeutic purposes 4Dental Pain Guidance UKMi October 2015

5. Single dose overdoses ‘Classic’ overdose scenario Possible self-harm Impulses may last 30 mins, then regret and seek help Alcohol related Peak age range 15-24 years; Women > Men Refer these calls – large single doses are unlikely to be an accidental overdose Dental pain – more likely to be staggered overdoses over a period of time 5Dental Pain Guidance UKMi October 2015

6. WHO Analgesic ladder for acute & chronic pain Mild Pain Step 1 Simple painkillers Paracetamol NSAID (e.g.Ibuprofen) Severe Pain Step 3 Strong opioids Morphine Tramadol Oxycodone Moderate Pain Step 2 Weaker opioids Codeine Dihydrocodeine Co-codamol Co-dydramol If pain persists 6Dental Pain Guidance UKMi October 2015

7. First line treatment of pain First choice Single painkiller at full dose Options if paracetamol alone or ibuprofen alone do not control symptoms For adults - consider an analgesic higher up the pain control ladder e.g. co- codamol Take regular paracetamol, if get breakthrough pain towards end of dose interval - take single dose of ibuprofen (or other way around) Risks if advise regular alternate doses of paracetamol and ibuprofen Confuse / forget what has been taken Delay diagnosis of a more serious condition Step 1: Simple painkiller Paracetamol Ibuprofen Step 2: Weak opioid Codeine Dihydrocodeine Co-codamol Co-dydramol Step 3: Strong opioid Morphine Tramadol Oxycodone

8. Paracetamol Uses Relieves mild to moderate pain Reduces fever Licensed for use in children from 2 months by mouth Side effects Not usually a problem at recommended dose Dangerous in overdose Patients ingesting 75mg/kg/24hr or more should be referred to hospital Potentially fatal liver damage Kidney damage (less often) Dose Maximum adult dose 8 x 500mg tablets in 24 hours Cautions Patients with liver problems Patients with kidney problems Drug interactions Does not interact with many medicines Must not be taken with other paracetamol containing medicines due to overdose risk 8Dental Pain Guidance UKMi October 2015

9. Dangers of paracetamol in overdose Very safe if used appropriately, but…. Highly toxic in overdose Supra-therapeutic doses may be as toxic as a one-off single overdose Be aware of hidden sources e.g. cold remedies, combination- medicines The more serious effects can be delayed Abdominal pain 12-36 hours Delayed hepatotoxicity 2-3 days before liver function declines Antidote must be given as soon as possible to be effective 9Dental Pain Guidance UKMi October 2015

10. Combination analgesics Co-codamolCodeine & paracetamolParacodol ® Panadol Ultra ® Solpadeine ® Co-dydramolDihydrocodeine & paracetamol Paramol ® Many painkillers contain more than one drug and are known as combination, compound or co-analgesics Codeine and dihydrocodeine are stronger than paracetamol or ibuprofen and are known as opioid analgesics Co-analgesics available OTC can be used for short-term pain not relieved by paracetamol or ibuprofen Do not use for more than 3 days unless advised by doctor.

11. Brand names Many Over-the-Counter (OTC) medicines have the same brand name attached to different products Similar sounding and looking products have different ingredients so it is important to obtain the exact name e.g. Lemsip Max Flu Lemon contains paracetamol Lemsip Max Flu 12 hour capsules contain ibuprofen Although both these products are called Lemsip Max, they contain completely different analgesics 11Dental Pain Guidance UKMi October 2015

12. Ibuprofen Uses Relieves mild to moderate pain Reduces fever Reduces inflammation Licensed for children from 3 months if 5kg or more Side effects Heartburn / indigestion Stomach ulcers Bleeding Contra-indications (must not take) Allergic to aspirin Previous peptic ulcer / bleed Taking another NSAID Severe heart failure Cautions (take only on advice) Asthma Kidney or liver problems High blood pressure Drug interactions Interacts with a number of other medicines Check the patient information leaflet for advice about other medicines Allergy Rash Wheezing / breathlessness 12Dental Pain Guidance UKMi October 2015

13. Ibuprofen overdose Although it has a number of side effects with therapeutic use it has quite low toxicity in overdose Most patients develop no more than: Nausea, vomiting, epigastric pain or more rarely diarrhoea Tinnitus, headache, GI bleeding also possible Acute kidney damage - most serious complication (large doses) CNS toxicity in serious overdose 13Dental Pain Guidance UKMi October 2015

14. Ibuprofen – different salts Ibuprofen products are most commonly available as “plain” ibuprofen Ibuprofen is also available in other forms in some products The following few slides describe non-standard ibuprofen products and their equivalencies Dental Pain Guidance UKMi October 201514

15. Ibuprofen Lysine Nurofen brand Nurofen Express 342mg Nurofen Express 684mg Nurofen Migraine Pain / Tension Headache 342mg Nurofen Maximum Strength Migraine Pain 684mg Plus others Paramed Migraine Relief 342mg Superdrug Migraine Relief 342mg Sainsbury's Migraine Relief 342mg Boots Rapid Ibuprofen Lysine 342 mg Morrisons Migraine Relief 342mg Tesco Migraine Relief 342mg Tesco Express Pain Relief 342 mg Asda Migraine Relief 342mg Feminax Express 342 mg 342 mg equivalent to 200 mg ibuprofen 684 mg equivalent to 400 mg ibuprofen 15Dental Pain Guidance UKMi October 2015

16. Ibuprofen Sodium Nurofen brand Nurofen Express 256mg 256 mg equivalent to 200 mg ibuprofen 512 mg equivalent to 400 mg ibuprofen 16Dental Pain Guidance UKMi October 2015

17. Ibuprofen 300mg Sustained Release Adults and children over 12 years: 1 capsule twice a day. Maximum 4 capsules in 24 hours Children under 12 years: Not to be given Do not take more frequently than every 8 hours Not to be chewed or sucked  Not the usual strength or release pattern of ibuprofen  Refer for further guidance if necessary Nurofen Back Pain 300mg SR Capsules ® 17Dental Pain Guidance UKMi October 2015

18. Nuromol ® Ibuprofen 200mg with Paracetamol 500mg Adults over 18 years: 1-2 tablets up to three times a day. Maximum 6 tablets in any 24 hour period Under 18 years: Not to be taken Leave at least 6 hours between doses  No matter how many tablets are taken, the paracetamol will cause toxicity before the ibuprofen  Calculate total amount of paracetamol taken 18Dental Pain Guidance UKMi October 2015

19. Table 1: List of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) ACECLOFENACACEMETACINASPIRIN (incl. low dose) AZAPROPAZONE CELECOXIBDEXIBUPROFENDEXKETOPROFENDICLOFENAC ETODOLACETORICOXIBFENBUFENFENOPROFEN FLURBIPROFENIBUPROFENINDOMETACINKETOPROFEN KETORALACMEFENAMIC ACIDMELOXICAMNABUMETONE NAPROXENPARECOXIBPIROXICAMPHENYLBUTAZONE SALICYLATESALICYLIC ACIDSULINDACTENOXICAM TIAPROFENIC ACID 19Dental Pain Guidance UKMi October 2015

20. Tell the caller:  The recommended OTC dose of ibuprofen is 1 x 400mg or 2 x 200mg every 6-8 hours but no more than 3 x 400mg or 6 x 200mg (1200mg) in 24 hours  Be aware of hidden sources of ibuprofen (e.g. in cold remedies, muscle creams)  Do not take any other anti-inflammatory medicines (NSAIDs) (except in oral gels) when taking ibuprofen (see list of NSAIDs in Table 1)  You can restart ibuprofen provided you do not take more than 1200mg (3 x 400mg or 6 x 200mg) ibuprofen in any 24 hour period Ibuprofen 20Dental Pain Guidance UKMi October 2015

21. Codeine An overdose of tablets containing codeine: Co-codamol 30/500 Co-codamol 8/500 May cause drowsiness, constipation, GI upset Severe - respiratory depression 21Dental Pain Guidance UKMi October 2015

22. Co-analgesics Co-Codamol = Codeine & Paracetamol Amount of codeine in co-codamol can be 8mg, 15mg or 30mg. Co-codamol 8/500 OTC Codeine 8mg & paracetamol 500mg Brands: e.g. Feminax ®, Migraleve Yellow ®, Panadol Ultra ®, Paracodol ®, Panadeine ® Co-codamol 15/500 POM Codeine 15mg & paracetamol 500mg Brands: e.g. Codipar ® Co-codamol 30/500 POM Codeine 30mg & paracetamol 500mg Brands: e.g. Kapake ®, Tylex ®, Solpadol ® 22Dental Pain Guidance UKMi October 2015

23. Co-Dydramol = Dihydrocodeine & Paracetamol Amount of dihydrocodeine can be 7.46mg, 10mg, 20mg, 30mg. Co-dydramol OTC Paracetamol 500mg, dihydrocodeine 7.46mg Paramol ® Co-dydramol POM Paracetamol 500mg + dihydrocodeine 10mg If no strength specified on the prescription. Co-dydramol POM Paracetamol 500mg + dihydrocodeine 20mg Remedeine ® Co-dydramol POM Paracetamol 500mg + dihydrocodeine 30mg Remedeine Forte ® 23Dental Pain Guidance UKMi October 2015

24. Co-Codamol / Co-dydramol Uses Mild to moderate pain Lowers fever (paracetamol alone is first choice) Side effects Codeine / Dihydrocodeine  collapse, drowsiness, confusion, constipation Paracetamol overdose 150 mg/kg/24hr or if risk factors, 75mg/kg/24hr Cautions Kidney or liver problems Limit use to 3 days unless advised by doctor Drug interactions Other paracetamol and / or opiate containing medicines Antidepressants Anti-anxiety medicines / sleeping tablets Check the patient information leaflet for advice about other medicines 24Dental Pain Guidance UKMi October 2015

25. Guidance for restarting paracetamol following inadvertent overdose This is designed to help you deal with patients who have taken more than the recommended amount of paracetamol but less than a toxic amount requiring referral Commonly, these patients will want to know when they can take their next dose of paracetamol. However we need to ensure not to restart too soon which would put them back into an overdose situation again Advise the patient that they may restart such that they take no more than the maximum recommended amount in any 24 hour period. i.e. 8 x 500mg (4000mg) paracetamol in 24 hrs The easiest way to do this is to use a timeline and mark the 24 hour period. It is important to check exactly how much has been taken and at what times 25Dental Pain Guidance UKMi October 2015

26. Restarting guidance case study 46 years old Symptoms of toothache No medical health issues, no other medicines, no allergies Has taken Paracetamol 500mg tablets Friday : 08:00 - 2 tablets 12:30 - 2 tablets 18:00 - 2 tablets 21:00 - 2 tablets 23:00 - 2 tablets Saturday: 07:00 - 2 tablets When can she take her next dose? 26Dental Pain Guidance UKMi October 2015

27. Restarting guidance Step 1: Draw a timeline Step 2: Fill in the doses the patient has taken Step 3: Find how many tablets the patient has taken in the last 24 hours Step 4: At 8am when the caller rings, they have had 12 paracetamol tablets in the last 24 hours. Now you can “shift“ the 24 hour period along, until they are under the recommended amount in 24 hours (the amount on the pack, which is 8 x 500mg tablets in 24 hours) Step 5: Work out how many paracetamol tablets the patient can still have in this 24 hour period. Restart so that there is the recommended dose interval (4 hrs for paracetamol) since the last dose was taken 27Dental Pain Guidance UKMi October 2015

28. Restarting guidance Day 1 Day 2 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 At 8:00 - 12 tablets have been taken in the preceding 24 hours 08:00 Phones Service

29. Restarting guidance Day 1 Day 2 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 At 12:00 - 10 tablets have been taken in the preceding 24 hours 08:00 Phones Service

30. Restarting guidance Day 1 Day 2 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 At 16:00 - 8 tablets have been taken in the preceding 24 hours 08:00 Phones Service

31. Restarting guidance Day 1 Day 2 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 At 18:30 - 6 tablets have been taken in the preceding 24 hours The patient can restart paracetamol by taking another two tablets at 18:30 hours 08:00 Phones Service